Patients with poor-prognosis testicular cancer
have a better chance of surviving if they are treated at an
institution that cares for five or more such patients during an
approximate 4-year period than if treated at an institution that sees
fewer than five patients during the same period. The study was
published by Laurence Collette, msc, of the European Organization for
Research and Treatment of Cancer (EORTC), and colleagues, in the May
19th issue of the Journal of the National Cancer Institute.

Investigators analyzed data on 380 patients treated between 1990 and
1994 in a randomized, phase III trial conducted by the EORTC and the
Medical Research Council of the United Kingdom. The 380 patients
received treatment at one of 49 participating institutions in 11
countries. These institutions were classified according to the total
number of patients that they entered into the studyfewer than 5
(26 institutions), 5 to 9 (7 institutions), 10 to 19 (12
institutions), or 20 and more (4 institutions). The main end point
for analyzing the effect of the treating institution was overall survival.

Risk of Death Almost Double

The risk of death among patients treated at the 26 institutions
enrolling fewer than five patients was almost double the risk
observed in the 23 institutions treating five or more patients
(hazard ratio, 1.85; 95% confidence interval, 1.16 to 3.03). In
addition, 13% of the patients treated in centers enrolling fewer than
five patients died of treatment-related causes, compared with 6% of
patients treated in institutions that entered larger numbers of patients.

According to the authors, the poorer results at centers enrolling
fewer than five patients stem from a combination of factors. These
include a greater tendency to reduce the dose of chemotherapy and to
delay treatment cycles, and the greater possibility that surgery to
remove residual lesions would not be performed at these institutions.
The combined impact of these factors is clinically important, and in
this analysis, the treating institution appears to be as strong a
predictor of survival as the patients disease status at study
entry. However, a prospective study is needed to confirm these results.

Results Characterized as Discouraging

In an editorial, Eric Feuer, PhD, of the National Cancer Institute,
and Joel Sheinfeld, MD, and George Bosl, MD, both of Memorial
Sloan-Kettering Cancer Center, note that the results of this study
are discouraging given the high cure rate for testicular cancer and
the widespread knowledge of treatment success. They cite other
studies that have also shown a positive association between patient
outcome and number of patients treated, and they describe some
cautions necessary in interpreting these studies.

The editorialists conclude that, in the case of relatively rare
cancers, such as germ cell tumors, it is difficult for centers to
accrue the critical mass of patients needed to allow
physicians to become expert in managing the disease, and that
patients should be treated by experts to ensure the highest cure rate.

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